RU2657825C1 - Method for predicting acute renal and hepatic insufficiency - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, and can be used to predict the development of acute renal-hepatic insufficiency in patients with acute surgical pathology. Essence of the method: in patients with acute surgical abdominal pathology daily, starting from the first day after surgical treatment, in dynamics, the content of molecules of medium mass, creatinine, bilirubin and malonic dialdehyde is determined in venous blood, on the basis of which the index of prognosis for acute renal and hepatic insufficiency (IP ARHI) is calculated according to the formula: $$\text{IP ARHI}=\text{(MSM}+\frac{{\text{K}}_{\text{2}}}{{\text{K}}_{\text{1}}}+\frac{{\text{B}}_{\text{2}}}{{\text{B}}_{\text{1}}}\text{)}\cdot \frac{{\text{MDA}}_{\text{2}}}{\text{MDA}{}_{\text{1}}},$$

where the MSM₂ – content of molecules of medium mass at the current moment, MSM₁ – content of molecules of medium mass at the previous moment, K₂ – content of creatinine at the current time, K₁ – content of creatinine at the previous time, B₂ – content of bilirubin at the current moment, B₁ – content of bilirubin at the previous moment, MDA₂ – content of malonic dialdehyde at the current moment, MDA₁ – content of malonic dialdehyde at the previous moment. Value of the prognostic index of the ARHI less than 3.34 states that there is no probability of developing acute renal and hepatic insufficiency, from 3.35 to 4.19 suggests a low probability of progression of ARHI, from 4.20 or more suggests a high probability of progression of ARHI.

EFFECT: invention improves accuracy of predicting ARHI and its adequate assessment of severity by establishing the severity of membrane-destructive phenomena, which allows for timely measures to correct therapy.

1 cl, 3 tbl, 2 ex

Description

The invention relates to medicine, in particular to surgery, and can be used to predict the development of acute renal hepatic failure in patients with acute surgical pathology.

Prediction of the development of acute liver failure is most often based on a comprehensive assessment of bilirubinemia, fermentemia, albuminemia and other laboratory parameters. However, with a high rate of development of hepatic dysfunction and with impaired intrahepatic blood flow, when the rate of leaching of markers of damage to hepatocytes is impaired, indicators of impaired pigment metabolism, protein synthesis, liver cell metabolism, cholestasis, cytolysis and others do not always accurately determine the likelihood of developing this life-threatening syndrome (Ivashkin V.T., Nadinskaya M.Yu., Zolotarevsky V.B., ed. Diseases of the liver and biliary tract: A Guide for Physicians. M-Vesti, 2002. 647 from.).

There are methods that allow you to evaluate the already formed acute liver failure by clinical and laboratory parameters (oligoanuria, intoxication) and biochemical parameters (increase in urea nitrogen, creatinine, residual nitrogen, increase in potassium, decrease in calcium and sodium (Smirnov A.V., Kayukov I.G., Degtyareva O.A., Dobronravov V.A., Rumyantsev A.Sh., Raffari T.N., Zverkov R.V. Problems of diagnosis and stratification of the severity of acute kidney damage // Nephrology, 2009. Volume 13 No. 3. P. 9-18)). Urine volume measurement is also used. However, this is a not very specific characteristic of the functional state of the kidneys, since the volume of urine excreted depends on a number of factors (Bellomo R., Ronco C., Kellum JA, Mehta RL, Palevsky P. Acute Dialysis Quality Initiative workgroup. Acute renal failure - definition, outcome measures , animal models, fluid therapy and information technology needs // The Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit. Care. 2004; 8 (4): R.204-212). Currently, determination of urinary and serum creatinine levels is the most common test of kidney functional status, reflecting glomerular filtration rate. These parameters have no alternatives for assessing renal function in an acute situation (Coca SG, Parikh CR Urinary biomarkers for acute kidney injury: perspectives on translation. Clin. J. Am. Soc. Nephrol. 2008; 3 (2): 481-490) .

The closest in technical essence to the claimed solution is a method for the diagnosis of acute renal failure, which is based on the determination of the concentration in the blood and urine of urea, creatinine, sodium, potassium, osmolarity with subsequent calculations and the establishment of concentration indices (Verkhovsky B.D. Extracorporeal hemodialysis in therapy of acute and chronic renal failure. Abstract of dissertation for the degree of Doctor of Medical Sciences, Moscow, 1977. S. 9-10).

However, the known method is cumbersome, requires appropriate laboratory reagents and the necessary medical equipment - an osmometer, a plasma photometer or microlite. In addition, it is necessary to carefully monitor the minute / daily urine output, and subsequently calculate the concentration indices. However, there is no reliable ability to predict the outcome of the disease.

The technical result consists in increasing the accuracy of prediction of acute renal hepatic failure and its adequate assessment of severity by establishing the severity of membrane-destructive phenomena, which allows timely measures to be taken to correct therapy.

The essence of the invention lies in the fact that in a method for predicting acute renal hepatic failure in patients with acute surgical abdominal pathology daily, starting from the first day after surgical treatment, the content of medium-weight molecules, creatinine, bilirubin and malondialdehyde in the venous blood is determined in dynamics based on which the forecast index of acute renal hepatic failure is calculated by the formula:

$$\text{IOPS}=\text{(}\frac{{\text{<figure-callout id="2" label="MSM" filenames="00000006.png" state="{{state}}">MSM</figure-callout>}}_{\text{2}}}{{\text{MSM}}_{\text{one}}}+\frac{{\text{TO}}_{\text{2}}}{{\text{TO}}_{\text{one}}}+\frac{{\text{B}}_{\text{2}}}{{\text{B}}_{\text{one}}}\text{)}\cdot \frac{{\text{<figure-callout id="2" label="MDA" filenames="00000006.png" state="{{state}}">MDA</figure-callout>}}_{\text{2}}}{\text{MDA}{}_{\text{one}}},$$

where IP OPPN - index for predicting acute renal hepatic failure,

MSM ₂ - the content of molecules of medium weight at the moment,

MSM ₁ - the content of molecules of medium weight at the previous moment,

K ₂ - the content of creatinine at the moment,

K ₁ - creatinine content at the previous moment,

B ₂ - the current bilirubin content,

B ₁ - the bilirubin content at the previous moment,

MDA ₂ - the content of malondialdehyde at the moment,

MDA ₁ - the content of malondialdehyde at the previous moment,

the value of the index of prediction of acute renal hepatic insufficiency in dynamics of less than 3.34 indicates the absence of the likelihood of developing acute renal hepatic insufficiency, from 3.35 to 4.19 suggests a low degree of probability of progression of acute renal hepatic failure, from 4.20 and more suggests a high degree of likelihood of progression of acute renal hepatic failure.

The novelty of the proposed method is as follows:

1. For the first time, not a static assessment of the level of a number of indicators of the functional state of the kidneys and liver is carried out, but their most probable forecasting in the near term of the observation period is determined.

2. Not only the severity of functional disorders of the kidneys and liver is assessed by known indicators (by the level of medium-weight molecules, creatinine, bilirubin), but also the intensity of one of the most important processes (lipid peroxidation), which disrupt the functional state of the cells of these organs, is determined.

3. The basis for calculating the prognosis index of acute renal hepatic insufficiency is taken not only the current moment, but also the previous one.

The method is as follows.

In patients with acute surgical abdominal pathology (peritonitis, pancreatitis, etc.), the content of medium-weight molecules (MSM), creatinine, bilirubin and malondialdehyde (MDA) in the venous blood is determined daily during the early postoperative period of the patient's stay in the clinic. This is due to the fact that in acute surgical pathology, much attention is paid to the development of acute renal hepatic failure, which can lead to the progression of the underlying disease, the development of other organ failure and the death of the patient. Timely diagnosis, and, more importantly, prediction of this pathological condition with urgent pathology is very significant for the appointment of adequate therapy for its timely correction. The results of such studies can also evaluate its effectiveness in the dynamics of treatment and timely appointment of repeated operations.

The content of creatinine and bilirubin is carried out according to known routine tests.

Determination of the content of MSM. Blood serum is mixed with a 10% solution of trichloroacetic acid in a ratio of 1: 2, centrifuged for 30 minutes at a speed of 3000 g. Then, 0.5 ml of the supernatant is mixed with 4.5 ml of distilled water, and the optical density is measured on an SF-46 spectrophotometer at a wavelength of 254 nm. The result is expressed in arbitrary units (Pikuza O.I., Shakirova L.Z., 1994).

Determination of the content of MDA. To 1 ml of blood plasma add 3 ml of 1% phosphoric acid containing 0.5 mmol of EDTA and 1 ml of a 0.5% solution of 2-thiobarbituric acid. Samples are mixed and incubated for 45 min at 100 ° C. Then the samples are cooled and poured 4 ml of n-butanol, shaken thoroughly and centrifuged for 15 min at 1500 g. In the upper butanol phase, the absorption spectrum is recorded in the region of 515-550 nm. The optical density at 532 nm was determined using the spectrum as a base point at 515 and 550 nm. The content of TBA-reacting products is expressed in nmol / g protein (Egorov D.Yu., Kozlov A.V., 1988).

Based on the obtained laboratory data on the content of MSM, MDA, creatinine, bilirubin in venous blood, the index for predicting acute renal hepatic failure (PI OPPN) is calculated by the formula:

$$\text{IP OPPN}=\text{(}\frac{{\text{<figure-callout id="2" label="MSM" filenames="00000006.png" state="{{state}}">MSM</figure-callout>}}_{\text{2}}}{{\text{MSM}}_{\text{one}}}+\frac{{\text{TO}}_{\text{2}}}{{\text{TO}}_{\text{one}}}+\frac{{\text{B}}_{\text{2}}}{{\text{B}}_{\text{one}}}\text{)}\cdot \frac{{\text{<figure-callout id="2" label="MDA" filenames="00000006.png" state="{{state}}">MDA</figure-callout>}}_{\text{2}}}{\text{MDA}{}_{\text{one}}},$$

where MSM ₂ is the content of molecules of average weight at the moment,

MSM ₁ - the content of molecules of medium weight at the previous moment,

K ₂ - the content of creatinine at the moment,

K ₁ - creatinine content at the previous moment,

B ₂ - the current bilirubin content,

B ₁ - the bilirubin content at the previous moment,

MDA ₂ - the content of malondialdehyde at the moment,

MDA ₁ - the content of malondialdehyde at the previous moment.

The value of the prognosis index of acute renal hepatic insufficiency of less than 3.34 indicates the absence of the likelihood of developing acute renal hepatic insufficiency and states the adequacy of the therapy.

The value of the prognosis index of acute renal hepatic insufficiency from 3.35 to 4.19 suggests a low degree of probability of progression of acute renal hepatic insufficiency and causes the appointment of traditional infusion-transfusion detoxification therapy.

The value of the prognosis index of acute renal hepatic insufficiency of 4.20 or more suggests a high degree of probability of progression of acute renal hepatic insufficiency and causes the appointment of efferent detoxification methods or repeated surgical interventions (Table 1).

Thus, the determination of the index for predicting acute renal and hepatic insufficiency in patients with acute surgical pathology allows one to judge the direction (progression or relief) of the course of acute renal hepatic insufficiency syndrome and evaluate the dynamics of treatment effectiveness, as well as the effects of detoxification and efferent therapy.

Example 1. Patient S., was hospitalized in the surgery department of the city clinical hospital on 03/17/2015 with a diagnosis of acute appendicitis complicated by peritonitis. In an emergency after the preoperative preparation was operated. Operation: appendectomy, debridement, drainage of the abdominal cavity. Postoperative diagnosis: acute gangrenous-perforated appendicitis. Diffuse purulent peritonitis.

The indicators of endogenous intoxication, creatinine and bilirubin, lipid peroxidation and the index for predicting acute renal and hepatic insufficiency in patient C. with acute appendicitis and peritonitis in the early postoperative period are presented in the table. 2.

In the early postoperative period, based on data on the content of MSM, creatinine, bilirubin and MDA in venous blood for the first and second days, then for the second and third, third, fourth, fourth and fifth days, the index for predicting acute renal hepatic failure was determined, which in at the beginning it was 3.35 (a low degree of probability of progression of DIAP), and in subsequent stages it was below 3.34 (there is no likelihood of progression of DIAP). Against the background of intensive infusion detoxification therapy, changes in these indicators became smaller. The early postoperative period was uneventful. 04.04.2015, the patient was discharged with recovery.

Example 2. Patient T. was hospitalized in the surgery department of the city clinical hospital on 05.24.2016 with a diagnosis of gastric ulcer complicated by perforation and peritonitis. In an emergency, after preoperative preparation, an operation was performed: laparotomy, suturing of a perforated gastric ulcer, sanitation and drainage of the abdominal cavity. Postoperative diagnosis: gastric ulcer. Perforation of an ulcer of lesser curvature of an organ. Common purulent-fibrinous peritonitis.

The indicators of endogenous intoxication, creatinine and bilirubin, lipid peroxidation and the index for predicting acute renal and hepatic insufficiency of patient T. gastric ulcer complicated by perforation and peritonitis in the early postoperative period in dynamics are presented in table. 3.

In the early postoperative period, based on the data on the content of MSM, creatinine, bilirubin and MDA in venous blood for the first and second days, then for the second and third, third and fourth days, the prognosis index of acute renal hepatic failure was determined, which is two days after the operation amounted to 3.76 (a low degree of probability of progression of DIAP), after three days - 3.78 (a low degree of probability of progression of DIAP). The patient's therapy was corrected, however, after four days, the index for predicting acute renal hepatic failure became 4.41 (a high probability of progression of acute renal failure), which led to a radical review of the treatment regimen.

After four days, a second operation, during which the progression of peritonitis is registered. Performed reorganization of the abdominal cavity. Peritonitis is stopped, subsidence of the inflammatory process was accompanied by a decrease in the prognosis index of acute renal hepatic failure. So, one day after the second operation (5 days after the first operation), it amounted to 1.43, two days after the second operation (6 days after the first operation) - 2.08, 3 days after the second operation (7 days after the first operations) - 1.52 (there is no likelihood of progression of DFSA). The patient was discharged 25 days after the first operation with recovery.

Compared with the known solution, the proposed one allows to increase the accuracy of prediction of acute renal hepatic failure and its adequate assessment of the severity at the current moment, early determination (prediction) of the dynamics of this severe syndrome in the near future, since it allows you to evaluate not only the severity of functional impairment of the kidneys and liver, but also to establish the state of one of the main trigger mechanisms of organ cell dysfunction - the severity of membrane-destructive phenomena, which makes it possible to take timely measures to correct therapy.

Claims (12)

A method for predicting acute renal hepatic failure, including venous blood tests for creatinine, bilirubin, characterized in that daily, starting from the first day after surgical treatment, the content of medium-weight molecules, creatinine, bilirubin and malondialdehyde is determined in dynamics, based on which calculate the index for predicting acute renal hepatic failure according to the formula: $$\text{IP OPPN}=\text{(}\frac{{\text{MSM}}_{\text{2}}}{{\text{MSM}}_{\text{one}}}+\frac{{\text{TO}}_{\text{2}}}{{\text{TO}}_{\text{one}}}+\frac{{\text{B}}_{\text{2}}}{{\text{B}}_{\text{one}}}\text{)}\cdot \frac{{\text{MDA}}_{\text{2}}}{\text{MDA}{}_{\text{one}}},$$

where IP OPPN - index for predicting acute renal hepatic failure, MSM ₂ - the content of molecules of medium weight at the moment, MSM ₁ - the content of molecules of medium weight at the previous moment, K ₂ - the content of creatinine at the moment, K ₁ - creatinine content at the previous moment, B ₂ - the current bilirubin content, B ₁ - the bilirubin content at the previous moment, MDA ₂ - the content of malondialdehyde at the moment, MDA ₁ - the content of malondialdehyde at the previous moment, the value of the index for predicting acute renal hepatic failure of less than 3.34 states that there is no likelihood of developing acute renal hepatic failure, from 3.35 to 4.19 suggests a low degree of probability of progression of acute renal hepatic failure, from 4.20 or more suggests a high degree of likelihood of progression of acute renal hepatic failure.

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